Practical activities 1
Nursing action physical assessment of the respiratory system
Physical assessment nursing actionthe systembreathing, including inspection,
Palpation, percussion, and auscultation.
Physical assessment of the respiratory system
1. Understanding:
The physical assessment of the respiratory system is chest examination and
system
Bring with the way of inspection, palpation, percussion, and auscultation.
2. Destination:
Get objective data from the chest shape and respiratory function, through
Inspection, palpation, percussion, and auscultation.
3. Equipment:
Stethoscope
4. Steps:
a. Pre interaction stage:
1) Patient's needs / indication identification
2) Wash hands
3) Prepare a tool
breakfast. Orientation stage:
1) Give greetings, call the client with his name
2) Explain the objectives and action procedures
3) Give the opportunity to ask clients
C.. Workstage:
1) Encourage the client to take off the shirt.
2) Set the client's position (sit down, or lie down)
In accordance with examinations.
3) Give an explanation to the client what will be done.
4) Perform checks from the front, side, or back,
Includes walls, lungs and breathing.
5) Perform inspection:
a) Pay attention to the shape of the chest (ribs, sternum, diaphragm)
b) See Deviation
c) Pay attention to the intercostal space: melting, croiling,
or adanyaretraction at inspiration
d) Pay attention to the location and skapula form (from behind)
e) Pay attention to the road and the form of a vertebral column (noted
The presence of kifosis, scoliosis, and lordosis).
6) Do palpation:
a) Place both hands on the client's front chest, ask
Clients Interesting Breath, Feel Chest Movement, Compare
Right and left
b) Stand behind the client, place the palm, client
asked to take a breath, feel and compare the right and
the left
c) Feel the focal fremitus by the way clients are asked for
say seven-seven (77), then put the second
hands on the back of the chest and compare good
respiratory movement and sound fremitus between right
and left
d) Measure the chest circle during strong inspiration and expiration
strong.
7) Do it
Percussion:
Objective:
Determine the limit, size, position, and network quality
or tool (lung, heart)
Know whether organs contain air, liquid, or period
solid
a. The front lung
Client lying
Compare right and left
percussion systematically from top to bottom
Pay attention to the position of the heart and compare results
perkusinya
percussion in the supra clavicle fossa area,
then ask the client to raise both hands and
Perform percussion from the armpit
Determine the heart line
breakfast. Pulmonary and liver
Client keep lying, palpation from top to bottom
in which areas are pulmonary and liver limits, sounds
Sonor will change to Dullness
Give a sign at that line. In normal people
Healthy, this limit is located between Costa to 5 and 6.
C.. Rear
The client sits upright, starts from top to bottom
systematic, compare right and left (usually the area
the right lung percussion is higher than the area
left, because of the heart)
Determine the respiratory movement. Client requested
Breathe deeply, continue percussion down. On clients
healthy, the limit of the loss of the Sonor's voice will shift to
below. The difference between the loss of Sonor's voice
is the magnitude of lung development
8) Do auscultation:
Objective: Determine whether or not the respiratory tract change
maupunparu
a) The client was asked to take a breath slowly with the open mouth
b) Do a systematic auscultation. Listen every time
Actarscript of one inspiration period. Compare
Right and left
c) Start the front area above the clavicle down
d) Continue the back of the back from top to bottom
e) Note if there is a sound change, specify the location
f) Record the results of auscultation: vesicular, bronchhial, wheezing, ronkhi,
rales
d. Termination stage:
1) Evaluation of client results / responses
2) document the results
3) Contract for the next activity
4) End the activities, set up tools
5) hand washing
5. Reporting
a. Practical reports contain about: understanding, purpose, equipment, and
steps
breakfast. Practicum reports are collected according to the schedule that has been
determined by instructors.
Assessed aspects
A. Pre-interaction stage
1. Identify the needs / indication of the patient
2. Wash hands
3. Prepare tools
B. Phase orientation
1. Give greetings, call the client with his name
2. Explain the objectives and procedures of action
3. Provide an opportunity for clients to ask
C. Workstace
1. Encourage clients to take off clothes.
2. Set the client's position (sit down, stand up, or lie down)
According to the examination.
3. Perform checks from the front, side, or
Rear, covering the chest wall, lungs and breathing.
4. do inspection
5. Do palpation
6. Perform percussion
7. Do auscultation
8. Tidy up patients
D. termination stage
1. Evaluate the client's results / response
2. Documenting the results
3. Contracts for further activities
4. End the activity, clean up the tools
5. Wash hands
